Sepsis/Septic Shock RAPID Reasoning Case Study STUDENT

Sepsis/Septic Shock RAPID Reasoning Case Study STUDENT Jack Holmes, 72 years old Primary Concept Perfusion Interrelated Concepts (In order of emphasis) • Inflammation • Infection • Tissue Integrity • Clinical Judgment • Patient Education • Communication NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Case Study Safe and Effective Care Environment Management of Care 17-23%  Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12%  Psychosocial Integrity 6-12%  Physiological Integrity Basic Care and Comfort 6-12%  Pharmacological and Parenteral Therapies 12-18%  Reduction of Risk Potential 9-15%  Physiological Adaptation 11-17%  Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved. History of Present Problem: Jack Holmes a 72-year-old Caucasian male brought to the ED by ambulance from a skilled nursing facility (SNF). According to report from the paramedic, when the SNF nursing staff attempted to wake him this morning, he would not respond, and his BP was 74/40 with a MAP of 51. He has a history of Parkinson’s disease, COPD, CHF, HTN, depression, and a stage IV decubitus ulcer on his coccyx that developed three months ago. He does not follow commands, is unresponsive to verbal stimuli, but responds to a sternal rub with grimacing and withdrawing from stimulus. Personal/Social History: He has lived in the skilled nursing facility the past three years and has been bed bound the past year due to his advanced Parkinson’s disease. He was a heavy smoker, 1 PPD for 40 years until he moved to the SNF. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: Low BP with MAP of 51 Stage 4 Ulcer on his coccyx that developed 3 months ago COPD, CHF, HTN, Parkinson’s disease and old age Unresponsiveness to verbal stimuli Hypoperfusion of the tissue which can hinder oxygenation Ulcer not healing due to inadequate tissue perfusion Altered immune response due to these comorbidities and lowered functioning immune system given the patient’s age. Altered LOC RELEVANT Data from Social History: Clinical Significance: Skilled Nursing Facility More exposure to pathogens or iatrogenic illness at the facility Bed bound due to his Parkinson’s Poor skin integrity, atrophy of muscle, renal calculi, DVT, isolation Depression Isolation, no interest or motivation in performing ADL’s, unable to self-advocate, withdrawing from peers Patient Care Begins Current VS: P-Q-R-S-T Pain Assessment: T: 103.4 F/39.7 C (oral) Provoking/Palliative: Not responsive verbally, withdraws to pain, no other indicators of pain P: 135 (irregular) Quality: R: 32 (regular) Region/Radiation: BP: 76/39 MAP: 51 Severity: O2 sat: 91% 2 liters n/c Timing: What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: Temperature is high There is an active infection in the body, this can also cause higher metabolism which can lead to fatigue Respiration is high BP is low Compensating for low BP in order to adequately oxygenate the tissues O2 Sat is low (91%) This is an indication of septic shock Could be normal for a patient with COPD who is a heavy former smoker with a history of 1 PPD for 40 years.